Management of the rigid arthritic flatfoot in adults: triple arthrodesis

The traditional surgical treatment for adults with a rigid, arthritic flatfoot is a dual-incision triple arthrodesis. Over time, this procedure has proved to be reliable and reproducible in obtaining successful deformity correction through fusion and good clinical results. However, the traditional dual-incision triple arthrodesis is not without shortcomings. Early complications include lateral wound problems, malunion, and nonunion. Long-term follow-up of patients after a triple arthrodesis has shown that many develop adjacent joint arthritis at the ankle or midfoot. This particular problem should be considered an expected consequence, rather than a failure of the procedure. Although the indications for and surgical techniques used in triple arthrodesis have evolved and improved with time (predictably improving results in the intermediate term), the triple arthrodesis should be regarded as a salvage procedure. Certain measures can be taken by the surgeon to avoid some problems. If patients are at risk for lateral wound complications, the arthrodesis could be performed through a single medial incision. However, this can make some aspects of the CC fusion more difficult. Implants would have to be inserted percutaneously, which prevents the surgeon from using either staples or plates. If a patient were to need a lateral column lengthening through a CC distraction fusion, this would not be possible medially. If either the ST or CC joints have minimal degenerative changes, they could be spared through a double or modified double arthrodesis, respectively. Although these procedures that deviate from the traditional triple arthrodesis offer promise, further study is required to better define their role in treatment of the rigid, arthritic AAFD. Triple arthrodesis is, by no means, a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of hindfoot positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to anticipate postoperative problems and provide modifications in traditional technique for certain patients.